A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?

Inject 0.3 to 0.5 mL of the solution.

Select an injection site that is free of scar tissue.

Hold the needle at a 30° angle during injection.

Massage the site following the injection.

Answer and Explanation

The Correct Answer is B

A. Inject 0.3 to 0.5 mL of the solution: The typical volume for a tuberculin skin test is 0.1 mL.
B. Select an injection site that is free of scar tissue: Scar tissue can interfere with the reading of the tuberculin skin test, so a site free of scars should be selected.
C. Hold the needle at a 30° angle during injection: The needle should be held at a 5–15° angle for intradermal injections.
D. Massage the site following the injection: Massaging the site is not recommended as it could affect the accuracy of the test.

Nursing Test Bank

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Correct Answer is D

Explanation

A. "I understand that the medication can slow my heart rate.": Nitroglycerin works by dilating blood vessels, which can reduce blood pressure but does not significantly slow the heart rate.
B. "I am going to take the medication with food.": Nitroglycerin should be taken sublingually without food, as food can interfere with its absorption.
C. "I will take the medication every 10 minutes until the pain goes away.": The typical recommendation is to take 1 tablet every 5 minutes for up to 3 doses; if pain persists, seek medical attention.
D. "I should feel the effects of the medication within 5 minutes.": Sublingual nitroglycerin typically works within 1-3 minutes to relieve chest pain.

A. Urinary retention B. Dizziness C. Decreased appetite D. Hypertension

Correct Answer is B

Explanation

A. Urinary retention: Urinary retention is not a typical adverse effect of lorazepam.
B. Dizziness: Lorazepam, a benzodiazepine, commonly causes CNS effects such as dizziness, drowsiness, and confusion.
C. Decreased appetite: Appetite changes are not commonly associated with lorazepam.
D. Hypertension: Lorazepam may cause hypotension, not hypertension, especially with IV administration.

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Body System	Findings
Vital Signs/General History	Temperature 35.4 °C (97.6 °F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74 mmHg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week.
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client has varicose veins.
Cardiovascular/Respiratory	S1S2 auscultated. No murmurs. All peripheral pulses 2+. Lung sounds clear bilaterally.
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odorless. Last menstrual period was 3 months ago.
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities.

Prescribed Medication	Nursing Instruction
Albuterol	"Take your albuterol when you are having difficulty breathing.” "Hold your breath for 20 seconds when taking your albuterol.”
Salmeterol	"Take the salmeterol 5 minutes before the albuterol when you need both medications." "Take the salmeterol 2 times each day."
Fluticasone	"Rinse out your mouth after taking the fluticasone." "Take the fluticasone as needed for an asthma attack."

A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?

Correct Answer is D

Explanation

A nurse is caring for a client who has a new prescription for lorazepam. For which of the following adverse effects should the nurse monitor?

Correct Answer is B

Explanation

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